The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Monthly Archives: August 2013

Before I begin this posting, I would like to say a word about confidentiality. In my postings about children in the U.S., I avoid writing about specific children, preferring to create a composite of a number of children I have known that will best illustrate the point I am making. When I write about children in other countries I do the same. I have begun to visit a number of orphanages in El Salvador, and in order to protect the confidentiality of the children in these homes, I will avoid referring to specific homes and also disguise the children in other ways.

This posting is about my recent trip to El Salvador.

By the time I reach the gate of my flight to El Salvador – in Houston or Miami – I begin to feel that I am almost there. Spanish is the language most spoken at the gate. The passengers include many people of modest means preparing to return home or to visit relatives. Sometimes I imagine there is an appreciative attitude of the passengers on the plane, as if they feel lucky to be there, rather than hassled by yet another plane trip. After arrival at the San Salvador Airport, and after passing through immigration, the tropical air surrounds me with warmth and moisture, tropical birds squawk in the trees outside the airport, and I have the full sensory experience of really being there. A large crowd is always waiting to greet relatives. There is more emotional energy in the crowd – more intensity – than in the relatively restrained crowds waiting in U.S. and Western European airports.

This time taking my hotel’s shuttle into the city, I relax and enjoy the familiar images of the drive. Pick-up trucks with dozens of people sitting in the back or standing and hanging onto the sides, buses that light up at night when they stop to discharge or pick up passengers, illuminating a multitude of people wearing bright colors, traffic diversions with orange cones directing you in circuitous routes for no reason I can determine (sometimes they are for the police to check your papers but sometimes there is no one there at all). This time I arrived at night and the dark hills were spotted with the lights of civilization.

Whenever I come here, I have an idea that I want to communicate to the caregivers and a plan of how I want to do that. Every time I come, during the course of my visit I completely fracture my original plan and end up with something else. It is an exciting experience.

This time I came with the plan of helping both the staff and the children to tell their life stories. The idea was inspired by a young colleague of mine, Molly, who was going to spend some time at one of the homes and was interested in the theme of life stories and how they are related to learning and the desire to learn. I also had in mind the AAI and the research correlating the “coherence” of the narrative of adults about their early caregiving experiences to the security of their attachment style in adult life and to their behavior as parents (Main, 2000). Since the kind of psychotherapy available in Boston is not possible for the children in the children’s homes of El Salvador, and since I am not sure that it would make sense for them anyway (Perry, 2008) I wondered if helping them tell their stories might be a possible therapeutic alternative.

In all of the homes I visited, my young colleague and I gathered the caregiving staff and asked the caregivers to tell stories about their lives. We did this because we hypothesized that through telling their own stories they could learn the value of telling stories. That might result in their encouraging the children to do the same. We asked them to begin with an event that occurred to them at the age of one of the children in their care. The stories they told included several memories of being bullied or teased, or even beaten, and how that experience served to help them empathize with the children they cared for. They also reported memories of being left alone in childhood or expected to take on excessive responsibility. Many told stories of struggling in school. One story was about a teacher being the only one to notice her sadness, during the time her parents were getting divorced.

We then asked the caregivers to tell a story about their parents. That question elicited stories of abandonment – temporarily or permanently, literally or emotionally – by their mothers. Father figures were either absent or deeply flawed – either harsh and punitive or alcoholic. Many caregivers were brought up by their grandmothers, and their grandmothers were generally described as kind and loving. Some of them told stories about their family members – mothers, fathers, older siblings – leaving them to find jobs in the U.S. I was reminded of the families I see sometimes at the Cambridge Hospital who have emigrated from El Salvador, leaving family behind. They represent the counterpoint of the caregivers in our groups. Some of the families in Cambridge willingly take in the children of debilitated relatives in El Salvador. Others avoid them, attempting to escape the guilt of having left behind the poverty and despair of their home country. The escape, though, is only partial, because their children – whom they are bringing to the child psychiatry clinic – always carry some of the burden of their parents’ painful past.

So, we – Molly and I – were trying to find a way of helping the children tell their stories. The trouble was that every way we thought of seemed artificial and we knew would fall flat. Then in the home I have been visiting the longest, a child asked me if I had videos of him when he was little. I promised to look for them, and the next day I brought the videos I had found to the home. The children were mesmerized by the videos of my first visit to this home, in 2004. Laughing, they called out the names of people they recognized in the film. Occasionally, they would ask about people whom they did not recognize, or they would misidentify a person who had left as someone who was still present. I wondered if the fact of their departure posed a threat that needed to be denied.

Sometimes I would stop the video and ask the children what they thought the child on the video was thinking and feeling. They had a hard time doing that. In one video, a little boy dropped something on the floor and then became preoccupied with his “misdeed”, looking down and up with big expressive eyes, in a sweetly comical manner. The children laughed and responded that he was clowning. They could not recognize that he was anxious and ashamed about having “broken a rule”. In another film a child was refusing to eat when being fed by the caregivers and later clearly demonstrated her intention of feeding herself. The children were able to identify her oppositionalism but not her expression of agency. I thought that showing them videos such as these and pausing the video at moments when emotion was expressed – as I did – could be an excellent tool to help them grow a “theory of mind”. Rather than the more artificial scenarios Molly and I had discarded as potentially stressful to the children, this was spontaneous and initiated by the children themselves.

The single woman director of one of the homes noted ruefully that since the children had gotten older, she had not been able to maintain the same routines that had been so organizing and comforting to them when they were younger. For example, she had previously begun each meal with group prayers led by one child at a time. The patterned rhythmic movement included in the clapping and singing of the prayers – I had always thought – contributed to the children’s ability to sit together at mealtime and talk to each other. This routine, and similar ones, seemed to help in regulating the children and making them feel secure. Now that the children in the home included a group of teenagers, meals were more chaotic and unpleasant, with less conversation and positive engagement among the children and caregivers. Struggling to maintain order and discipline in general, and feeling burdened by having to assume the role of disciplinarian, the director was loath to engage in yet another struggle. Yet mealtimes had been an opportunity to pull the “family”, together in the past, and a chance to reconnect with the spiritual core of the community, in the blessing. There was a powerful meaning to that ritual.

Coincident with my visit to the homes was the arrival of “The Navy”, an exciting event in which the US Navy stationed in the city sent a group of young navy men to do activities with the children. The children loved these experiences and adored the kind, strong, young men who came to play games with them. As I talked to the director in anticipation of the visit of “The Navy”, it occurred to me that the military was expert at discipline and team building. Maybe they could help. The next day when the officer, a personable and clearly intelligent young man in charge of the Navy team, introduced himself to me, I told him about my idea. Would he consider designing an exercise for the children to do at the beginning of the meal to help them organize “body and soul” for the day? He said he thought they could do that. When I expressed regret that I would not be able to see the product of their efforts, he promised to make a video and send it to me. In the absence of the regulating ritual of prayer at the beginning of meals, I had been been searching for another predictable ritual that could introduce movement and rhythm into the lives of the children. I knew that such a ritual could enhance their regulatory capacity. Maybe this was an answer. My hope was that, in addition to mealtime, the Navy could generalize the routine to homework time. But, one step at a time.

Transition from Foster Caregivers to Parent:
Luis is a 5-year old boy whose mother was a sex worker and gave him to her sister to care for when he was 1-year old. The sister was already taking care of Luis’ older sister, and she had two children of her own. When the sister moved in with a new boy friend, she could only take care of the sister and gave the then 2-year old Luis to a children’s home.

Luis’ mother was a young woman who had spent most of her childhood in a large orphanage, where she was alternatively neglected and abused. When she was 18 she left the orphanage and tried to find work but started using drugs with a boyfriend and became addicted. Unable to support her habit any other way, she became a sex worker. She first became pregnant with Luis’ sister and then with Luis, by different men. It is unknown whether she was using drugs during her pregnancies or whether the infants had problems at birth. The aunt did not notice any health problems in the babies, but did say that Luis was an irritable baby when he came to live with her at 1-year old. According to the aunt, Luis’ mother had wanted to care for him herself, especially after having to give up her first child, but her drug habit and her other activities resulted in her leaving him with neighbors and even strangers from time to time in a manner she herself acknowledged was neglectful.

When he entered the children’s home at 2-years old, he appeared to be a bright, engaging little boy who was, however, extremely anxious about losing control, for example, terrified of having an accident during potty training. This was despite the tolerant attitude the caregivers at the home had towards the toilet accidents of the toddlers. He seemed to thrive at the children’s home and became especially close to two other boys of the same age. He developed warm relationships with two female caregivers who worked with the “little boys” for the three years he was at the home. He loved the attention of the volunteers, especially the young men; some of them returned often to the home and developed real relationships with the children. Luis’ mother visited him in the home sporadically. He seemed pleased and interested in her visits, especially when she brought him presents, but as he got older he got upset when she brought the sister with her to visit and then mother and sister left together, even though the sister was actually living with the aunt.

When the LEPINA (http://www.unicef.org/about/annualreport/files/El_Salvador_COAR_2010.pdf , http://scrippsiij.blogspot.com/2012/12/lepina-law-harms-rather-than-helps.html) law was enacted in the country, it was ordered that he return to his mother. This was in spite of his mother not having a real home to take him to. The mother, anxious to have her son returned to her, told the court that she lived with her sister, and the court, anxious to comply with the law, accepted her statement. The children’s home was distressed at the decision, but they were unable to prevent Luis’ move back with his mother. They were worried not only that Luis would be leaving the home and his caregivers of three years, and not only that they deemed the mother incapable of caring for him at this time, but also they were afraid that the plans they had made for him to go to a good school would be jettisoned and that he would not begin school on time. They decided to work to build their relationship with his mother stronger and to try to support him in the neighborhood, but they were not optimistic.

How do you imagine that the Home could support this caregiver-child pair?

Jerry is a 13-year old boy who will not get off the computer. His mother in particular gets into terrible struggles with him when it is time to do his homework and he is intensely involved in a computer game that he refuses to leave. If it were not for his homework, his mother would not object as much, since he is developing skills in fine motor coordination, pattern analysis, and quick reaction time – to say nothing of his facility with computers! – And also he often engages in interactive games with his friends, which are collaborative as well as competitive and highly social. The main problem is that he does not do his homework. As soon as he comes home from school, he rushes to his computer and begins a game. When it is time for homework, supper, or bed, he refuses to get offline. (In response to a NY Times column about the subject, I found interesting comments from parents.)

It is not that Jerry does not care about school. He is very ambitious and conscious of the success of his slightly older sister, with whom he is highly competitive. He is discouraged about his school record and dreads receiving his report card, but he seems unable to accept help. When his teachers offer him extra help, he usually politely thanks them but does not show up for the scheduled session. He refuses any regular tutoring assistance. Last year he would ask his mother or father to sit in the room with him while he did his homework – although he would not allow them to help him in any concrete way – but this year he refuses any support from them. This drives them wild with feelings of worry and helplessness.

Jerry has always been an active, rather disorganized child, interested in sports and fairly good at them, but intense and prone to tantrums. He has such a short fuse that his parents and sister have tended to monitor his moods closely and when he is in “a bad mood”, “walk on eggshells” to avoid an outburst. His parents have extended themselves in many ways to try to make things better for him. They have helped him play the sports he choses and attended all of his games. They have advocated for him fiercely at school. Still, family life has been hard.

His mother says that when he is on the computer he is happy and excited, and completely involved. When he gets off the computer, he falls apart – becomes irritable, disorganized, infantile, and sometimes aggressive. When he acts like this, she tries to negotiate with him, but his negative behavior just escalates until a blowup. After that, when she tries to talk to him about what just happens, he either blows up again, or he leaves and slams the door behind him. His father sometimes has more luck with soothing him when he is irritable, but he is not much better at getting him to leave the computer or do his homework. His mother feels that she is always “the heavy” and expected to set limits and keep order in the home, while her husband comes and goes when it serves him. Sometimes she thinks that if he were “more present” as a father, Jerry would not be in trouble – and when she is at her wits’ end, she will tell him so – but other times she acknowledges that there is no simple answer for Jerry’s difficulties.

Both Jerry’s parents came from modest backgrounds and were exceptionally high achievers as children and adolescents. They now both have successful professional careers, though perhaps not at the level or degree of satisfaction that they had envisioned. Whereas his father had studied at Julliard and had imagined a career as a performing musician, he now teaches at a private school and works at composing music in his spare time. His mother, who had won national prizes as a figure skater, is now a coach.

This story is an elaboration of the “transition to school” posting, since it also involves homework. There is an excellent set of posts on the Child Mind Institute on transition to school that can be helpful to caregivers. They include good strategies to try first. A colleague has written a thoughtful blog post about the transition to kindergarten. Many of the children whose parents consult me have tried or could try these strategies without success. The story of Jerry is an example of such a case. My posting is to remind caregivers that each child is unique and has an inner world of his own, so that general strategies – no matter how intelligent or thoughtful – are sometimes not the answer. Rather, trying to imagine what is going on inside the child’s mind is the best way to start every effort to scaffold a difficult transition. Let me know what you imagine about what is in Jerry’s mind.

Courtney is a charming, gregarious, 4-year old African-American girl who will not go to bed at night. For 3 years, she has insisted on sleeping with her mother, and her father, who came from Haiti to Boston as a teenager, has long since slept alone. She is a restless sleeper and kicks her mother in her sleep, keeping her mother awake. The pattern began with the coincidence of two adverse events in the family. At 1-year old, Courtney was hospitalized briefly with bronchiolitis, and after her hospitalization she was diagnosed with asthma. At the same time, her father took a second job driving a taxi in order to meet the needs of his expanding family (he had two children from a previous family that he was helping to support).

After bringing Courtney home from the hospital, her mother took her into her bed to make sure she was breathing normally during the night. Her father went back to work at night and returned late in the morning. Courtney’s mother does not work outside the home but cares for two other children in an informal day care arrangement. Courtney’s mother is a beautiful young woman but looks tired and wan. She has lived in Boston for about 6 years now. She moved to Boston with an older sister from South Carolina, but her sister didn’t like the city and returned to the South. By that time, Courtney’s mother had met her now husband and decided to stay.

Courtney began kindergarten at the public school several months ago, in September. Her teacher described her as “active and curious”. She told her mother that Courtney had a hard time sitting still in circle time and had to sit next to the assistant teacher for support. Her speech was immature, and she was often disorganized and needed help following the classroom routine. She also told her mother that Courtney sometimes put her head down on her desk and seemed tired; the teacher asked her mother if Courtney were getting enough sleep. Courtney’s mother was unhappy with the progress reports, because she felt the teacher “did not know” Courtney. She thought that Courtney was smarter than her teacher gave her credit for. She also felt blamed by the teacher’s suggestion that Courtney might not be getting enough sleep.

Courtney’s mother is stricter with Courtney than with the other children in her care. She tells Courtney that she wants her to “grow up to be somebody”. She also reminds her that the way she can do that is to “do good in school”. She is determined to help her daughter succeed and worries that the school will not do their part. She gets very frustrated with Courtney for not sleeping in her own bed. She tells her, “When I was growing up, I had to sleep in a bed with three kids! Now you have a bed of your very own, and you won’t sleep in it! What’s the matter with you?!”

Here is the second illustration of a child and caregiver, again the mother, having difficulty negotiating a transition. Again, I welcome comments from different types of child caregivers.

b. Transition to School:
Daniela is a 9-year old girl who refuses to go to school. It is now October, and she has missed 10 full days of school and come in late or left early at least another dozen times. This is very hard on her single mother, whose boss has told her she cannot miss more time from work. The last few times, her mother has left her at home, watching t.v.

Daniela lives with her mother, who emigrated from Central America 10 years ago, in a studio apartment in city housing. She has never met her biological father, also from CA, but she calls her mother’s former boyfriend “Daddy”. Her mother told him to move out last year after a particularly violent fight. Her Daddy comes to see Daniela episodically and takes her to play at his mother’s apartment, where there are other children that the grandmother takes care of. Daniela enjoys these visits but sometimes is intimidated by the other children, especially an older boy.

Daniela is a quiet girl who has attends fourth grade at a public school in her city. Spanish is the only language spoken in her home, but her mother chose to have her enter an English only school so that she would learn English, and she quickly became fluent. Her mother’s English is minimal, and outside the home, Daniela often translates for her. Daniela seemed to do well in the first three years of school. She enjoyed going to school, and her progress reports described her as a bright, friendly girl with an aptitude for language and who was at least an average student in math. She had a few girl friends and was very attached to her teachers. Her kindergarten teachers and the teachers who taught her combined first and second grade classroom had the reputation of being the best teachers in the school. One teacher in each classroom spoke Spanish and a good relationship with Daniela’s mother.

However since last year, she speaks barely a word at school. Her mother blames the school for Daniela’s school refusal, because last year there were some bullies in her class. One boy in particular picked on her, making fun of her clothes and even making vulgar sexual remarks. The boy is not in her class this year, but she sees him on the playground at recess. Her mother wanted the school to expel the boy, but she was told that they could not do that. Also, for the past two years, Daniela’s teachers have not been as sympathetic to her or to her mother as her mother considers appropriate. They have told her mother that Daniela needs to make a bigger effort to participate in school, that other girls have tried to engage her, sit next to her at lunch, but Daniela does not respond.

Daniela began to fall behind in her schoolwork last year for the first time. She would tell her mother that she had no homework or had already done her homework, but later her teacher would send home notes telling her mother that Daniela’s assignments were missing or incomplete. This would make her mother frantic, and she would scream at Daniela to show her homework, but Daniela would only shut down.

This blog posting is a continuation of my writing on helping children make transitions – of all kinds. I am writing this with the awareness that very young children are much easier to help in this way even though it may not seem so at the time. In fact, it is possible that helping very young children to manage transitions could make this challenge easier for them later in childhood or even in adulthood, but this is not certain. It is always our wish that we could prevent future problems by addressing them early on, but that is not always the case. For that reason, I will also focus on helping older children and adolescents manage transitions. Since I am approaching these tasks as collaborative activities between child and caregiver, I will use a short cut and refer to C-CG as a unit.

As I write this I am also aware that the whole subject of making transitions cuts across many categories of concern for parents and other caregivers, as I mentioned in my previous posting. That is, for example, issues of regulation, compliance, motivation, learning, organization, emotion and mood, sensory, and probably many more. Here is an illustration of what I mean. In order to make the transition from home to school in the morning, the C-CG must manage the transition from sleep to wake (involving the organization of state and the regulatory challenges involved in the shifting from one physiological state to another), then the C-CG must organize the sequence of small tasks involved in preparing for the day – bathroom tasks, dressing, eating breakfast, etc. I use the word “organizing” consciously because putting all the small actions together is part of the challenge. I remember reading an article somewhere about a study in which subjects were tracked as they went through their day in a restricted space to demonstrate all the redundant movements and retraced steps they took (back to the refrigerator to get the milk after you had just gotten the butter out). The task of getting dressed – finding and choosing what you are going to wear, and putting on the clothing – may be complicated by varying degrees of discomfort if sensory hypersensitivity is a problem. Eating breakfast may be complicated by lack of appetite or (again) sensory sensitivities. Leaving the house is affected by feelings about leaving home and family and anxieties about what one will face in the challenging world of school.

All of these aspects of transition can be facilitated by three aids – 1) attention to regulation; 2) knowledge of specific strengths and vulnerabilities of the particular C-CG pair; and 3) routines and rituals. Each of these aids must be accompanied by the girl scout (it is probably in the boy scouts, too) motto of “Be Prepared”! Let’s go over them one by one.

1) Attention to regulationis extremely important for both members of the C-CG pair (in fact for the whole family or group). That means thinking ahead (Be Prepared) so that, for example, in managing the morning transitions, you can assure as much as possible that the C-CG is well rested. It means (Be Prepared) that adequate time, or even extra time, has been allocated for the task at hand. It also means that (again Be Prepared) that complications (someone else in the bathroom, another child interrupting with their own demands) are anticipated. It might mean that the CG has already had his/her cup of coffee. It might also mean that the CG is thinking about (has in mind) talking with his/her partner or a friend for support later in the morning.

2) Knowledge of the specific strengths and vulnerabilities of the particular C-CG pairis also crucial. The best way to illustrate this point is through examples. In fact, I have decided to try something new and to publish one example at a time, inviting my readers to post comments on the subject. What I would like you, as readers, to consider are the specific strengths and vulnerabilities of the C-CG pair I am writing about. Here is the first C-CG pair, of course, embedded in family and community environment:
a. Morning Transition:
Jamie is a smart, engaging Caucasian 3-year old boy who lives with his mother and father and his 1-year old sister in a large apartment downtown. His father has a job that requires him to travel and be away from home on average several days a month, and he often comes home from work late at night after Jamie is in bed and leaves for work again before Jamie wakes up. His mother left her professional job when her second child was born and they moved to Boston for a promotion in her husband’s company; she considers her primary role to be a mother. It was difficult for her when she perceived her first precious child as irritable and difficult to soothe, because she worried that she was doing something wrong and reading his cues incorrectly, but the pediatrician assured her that Jamie would grow out of it.
Transitions were a particular problem for the family. Bedtime was complicated because often Jamie would stay awake late in order to spend even a little time with his father after he came home from the office. Then when he would fuss about going to bed his father was reluctant to allow a negative exchange to spoil the good time they had together, so two goodnight books would turn into three, and three into four. The next morning it was very hard for his mother to get Jamie up to go to the preschool he attended in the mornings.

The worst problem for his mother is getting him up and ready in the morning – even when he has no school, but especially if there is a time constraint such as getting to school on time. His mother, fearful that the teacher would judge her for bringing him to school late, would focus all her attention on getting him out of the house and into the classroom. She would brush his teeth (usually not without a fight), dress him, and bring an energy bar with them for him to eat as breakfast in the car. Sometimes she even stopped and bought him a doughnut on the way, to sweeten the ride. She was often reduced to screaming at him when he stubbornly refused to cooperate with the simplest task, such as let her put his arm through the sleeve of his jacket. He would scream back at her. When this happened, she would glance with guilt at the 1-year old in the car seat and wonder what bad effect these screaming matches would have on her.

Leaving Jamie at school was also a challenge, since he would often cling and cry when it was time for her to leave. At first she would stay and try to help him get settled into play, but sometimes her daughter would start to fuss, and she concluded that the length of time she stayed didn’t seem to affect Jamie’s distress at her leaving. She felt awful leaving him there, crying. After that, his mother had barely finished the food shopping and other errands before it was time to pick up Jamie at school. She occasionally talked on the phone to her best friend, who lived in another city, but as the problems with Jamie grew, she started to avoid the other mothers at drop off and pick up time.

Please comment by suggesting ideas for what the particular strengths and weakness of the dyad of Jamie and his mother.

Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187). During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.